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Based onr record review and staff interview, it was determined that the facility failed to review and report finding of the review according to facility policy for 1 (#1) of 6 sampled patients. This practice does not ensure thorough review of patient concerns and identification of problems within the organization.


Findings include:


The facility's policy "Centralized Complaint/Grievance Management", no reference # listed, last revised 1/08 requires that the patient's grievance will be "reviewed, investigated and resolved within a reasonable time frame (7days)." It further indicates that "if a grievance will not be resolved, or if the investigation is not, or will not be completed within 7 days," (name of hospital) "will inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that" (name of hospital) "will follow up with a written response within 15 days". The Risk Manager presented the letter from the complainant and a copy of her medical record with some highlighted areas to the surveyor on 12/17/10 at approximately 11:00 a.m. She stated that she had received the complaint from the CEO, had obtained a copy of the patient ' s record and then had placed in a drawer in her office and had forgotten about it. She confirmed that she had begun the investigation by reviewing the medical record, but had not spoken with any of the staff involved and had not communicated with the complainant.

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure compliance with facility policy regarding use of restraint for 2 (#4, #5) of 6 sampled patients. This practice does not ensure safe and appropriate use of restraint.

Findings include:

1. The facility's policy "Restraints, Use of" number 900.A 305, last reviewed 8/10 requires a physician order for the restraint be obtained by physician or Licensed Independant Practitioner. A Registered Nurse (RN) may take a verbal order for the restraint, however, the order must be authenticated by the physician or LIP providing order within 24 hours. The policy also requires that if restraints are discontinued, a new order is required should the patient require the use of restraint again.


2. Patient #4 was admitted to the facility on 11/23/10. The physician gave a verbal order for restraint on 11/28/10 at 7:00 a.m. Review of nursing documentation revealed that the restraints were applied at 7 a.m. and removed 3 hours later at 11:00 a.m. The restraints were applied again at 7:00 p.m. There was no documentation of a new order having been obtained as required by policy. The Risk Manager confirmed the failure to follow the policy during interview on 12/16/10 at approximately 2:00 p.m.

3. Patient #5 was admitted to the facilit on 12/15/10 and was in the Intensive Care Unit at the time of the surveyor's visit. The physician gave a verbal order to the RN on 12/15/10 at 8:50 a.m. There order is authenticated by the physician, however, the date and time are not noted. It is therefore not possible to determine if the physician made a face to face assessment of the patient and authenticated the order within the required time frame. The Director of Nursing was in attendance during the review of the record and confirmed the lack of documentation.

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure a registered nurse evaluated the care provided to 1 (#1) of 6 sampled patients regarding oxygen therapy.

Findings include:

Patient #1 was admitted to the facility on 9/25/20 for a partial mastectomy and sentinel node biopsy. The attending physician wrote an order for oxygen therapy on 12/25/10. Review of the documentation by respiratory therapy revealed the patient was assessed on room air only two times. The oxygen saturation was documented as within normal limits at the time. On 9/27/10 at 9:00 a.m. the nurse noted an oxygen saturation of 89 % on room air, which is considered hypoxia according to the facility's policy "Oxygen Apparatus Set - Up", no reference # noted, last revised 7/09. The Licensed Practical Nurse (LPN) documented a saturation of 90% on room air at 7:40 a.m. on 9/28/10. The nurse also documented that the patient complained of feeling short of breath and having a difficult time taking a deep breath. There was no documentation that the pulmonologist who had been consulted was notified of this finding. There is documentation that the patient was on oxygen by nasal canula the remainder of 9/28/10 until discharge. The patient was discharged at 3:00 p.m. on 9/28/10 with no assessment as to how the patient maintained an appropriate oxygen saturation. The pulmonologist gave a verbal order to discharge the patient without oxygen on 9/28/20. The physician did not assess the patient on 9/28/10. There was no evidence in the medical record that he was made aware of the patients hypoxic episodes. The last pulmonary note was written on 9/27/10 and recorded the patient's oxygen saturation as 95% on 2 liters of oxygen. Interview with the Director of Nursing on 12/17/10 at approximately 9:30 a.m. confirmed the lack of assessment by a registered nurse regarding the patient's oxygen saturation status on room prior to discharge and lack of evidence that the physician was made aware of the patient's change in condition.

Based on record review and staff interview, it was determined that the facility failed to provide an appropriate discharge plan, based on patient needs and physician's order for 1 (#1) of 6 sampled patients. This practice does not ensure continuity of care following discharge from the hospital.

Findings include:

Based on record review and staff interview, it was determined that the facility failed to provide a satisfactory discharge plan based on patient needs. The medical record of patient #1 revealed that the patient was assessed within 24 hours of admission by the case manager. A note on 9/28/10 indicated that the physician ordered home care services. The home health care agency selected by the patient was notified. A note on 9/28/10 indicated that the patient phoned after she had arrived home that she was having difficulty breathing. The note further indicates that the durable medical equipment (DME) agency was notified to deliver DME to the patient ' s home. The type of equipment was not documented. A note dated 9/29/10 indicated that the DME agency was to deliver a nebulizer to the patient ' s hospital room, but the order was placed on hold by the physician. Review of physician orders revealed the attending physician wrote an order for the pulmonologist to be consulted to give discharge orders for oxygen and nebulizer treatment. The pulmonologist did not assess the patient on 9/28/10 but gave an order to send the patient home without oxygen and with an inhaler rather than nebulizer treatment. There was no evidence in the medical record that the pulmonologist had been aware of the patient ' s two hypoxic episodes on room air on 9/27/20 and 9/28/10. Review of the medical record of patient #1 from another acute care hospital to which the patient presented on 9/29/10 revealed that the patient was admitted for evaluation of hypoxia and was at the time in need of oxygen therapy. There was documentation by the attending in her discharge summary that the patient was sent home on nebulizer treatment and may need oxygen. Neither was provided at the time of discharge. During interview on 12/17/10 at approximately 10:30 a.m., the Director of Case Management stated that the nebulizer had been sent to the patient on 9/29/10 by the DME companybut this information was not documented in the medical record.

The Director of Nursing and CNO on 12/17/10 at 9:30 a.m. confirmed the documentation in the medical record presented some conflicting information and there appeared to be a lack of coordination in implementation of the patient's discharge plan.